Abstract:

Background: The implementation of decentralisation reforms in the health sector of Tanzania started in
the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to
improve the development of the health sector. Little is known about the impact of decentralisation on
recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health
workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of
health workers in 2006. The effects of this policy change are not yet documented. This study highlights the
experiences and challenges associated with decentralisation and the partial re-centralisation in relation to
the recruitment and distribution of health workers.
Methods: An exploratory qualitative study was conducted among informants recruited from five
underserved, remote districts of mainland Tanzania. Additional informants were recruited from the
central government, the NGO sector, international organisations and academia. A comparison of
decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary
for improving recruitment, distribution and retention of health workers.
Results: The study has shown that recruitment of health workers under a decentralised arrangement has
not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes
failure to get the required health workers. The study also revealed that recruitment of highly skilled health
workers under decentralised arrangements may be both very difficult and expensive. Decentralised
recruitment was perceived to be more effective in improving retention of the lower cadre health workers
within the districts. In contrast, the centralised arrangement was perceived to be more effective both in
recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention
of employees.
Conclusion: A combination of centralised and decentralised recruitment represents a promising hybrid
form of health sector organisation in managing human resources by bringing the benefits of two worlds
together. In order to ensure that the potential benefits of the two approaches are effectively integrated,
careful balancing defining the local-central relationships in the management of human resources needs to
be worked out.